If Everybody Agrees Primary Care is Broken, Why Can't We Fix It?

“Struggling against rising costs and a payment system that rewards procedure-based specialist care over spending time talking to patients and basic preventive medicine, family physicians and internists increasingly have had to squeeze in more patients for less pay… In order to fix this mess, we have to thoughtfully reshape the payment environment, says Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.”-- Wall Street Journal, January 31, 2008

“Reimbursement based primarily on the quantity of services delivered, rather than on quality, forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians… Serious effort is required to develop a national primary care payment policy. Public policy on primary care does not exist; the fortunes of primary care are dictated not by the healthcare needs of the country but by a specialty-rich, quantity-based reimbursement system. Few legislators, particularly among those responsible for the trend-setting Medicare program, are aware that primary care is struggling.”-- The New England Journal of Medicine, August 31, 2006

These two quotes are, I think, representative of the prevailing perception of the current poor health of primary care medicine, and of the possible (probable?) long-term effects if a remedy is not soon found. Everyone in the profession is aware of the dismal math informing the situation: inadequate and dwindling payment + increasing costs and overhead = the need to see more patients in less time = growing disaffection and disillusionment among current and long-time practitioners = fewer residents choosing to practice primary care = a looming shortage of vital healthcare professionals = decreasing access to needed care and growing patient dissatisfaction, and on and on.

It is rare to find such widespread consensus regarding the nature, causes, and theoretical solution to a problem of this magnitude. Which begs the question: if everyone more or less agrees about what is wrong, then why can’t we fix the problem? The answer to that question may be explained by a look at some of the institutional forces that affect the policies and decisions that determine how and how much physicians are paid.

Conspiracy Buffs Rejoice!

It appears there may be a shadowy “them” at least in part responsible for this mess. The Illuminati? Freemasons? Mensa? No, it’s something far more sinister: The AMA/Specialty Society Relative Value Scale Update Committee (RUC).

The AMA asserts the activities of this body are motivated by the AMA’s desire to advocate “for fair and accurate valuation for all physician services,” and to “ensure that physician services across all specialties are well-represented.” To this end, the RUC makes “annual recommendations regarding new and revised physician services to the Centers for Medicare and Medicaid Services.”

Pretty benign, so far: the RUC is an advisory committee, nothing more. But James Gaulte, author of the blog Retired Doc’s Thoughts, thinks there is more going on than first meets the eye. He posted some interesting observations on all this back in November, under the heading “The pathophysiology of primary care dwindles.” He identified the major cause of what he called “the primary care exodus” as “decreasing take-home pay… plus increasing third-party requirements and mandates, the threat of malpractice, and the perceived greener pastures of the non-primary care branches of medicine.” And the cause of this decrease in take-home pay? The CMS (Medicare) payment fee schedule and the RBRVS (the Resource-Based Relative Value Scale, the system used by Medicare to determine physician payments), which have failed to close the gap between payments to procedurists and primary care physicians. Perhaps this can be explained, suggested Dr. Gaulte, by the fact that procedure-based specialties are disproportionately represented on the RUC committee and that the AMA far understates the group’s influence on CMS decisions, noting a JAMA commentary that claims their advice “is put into motion about 80 % of the time by CMS.” [Actually, that JAMA article notes that “more than 90% of the RUC’s recommendations are accepted and enacted by CMS. — Ed.]

Dr. Gaulte summarizes: “There are wage controls on physicians’ fees. These are implemented by CMS with advice and consent from a procedurist-dominated, AMA sanctioned group, the RUC. The third-party payers follow suit. Wage controls lead to shortages (of primary care docs, who are disproportionately impacted), poorer quality and increased waiting times.”

Others have also picked up on this idea, including (but not limited to):

• The authors of an article in Annals of Internal Medicine

• The Health Care Renewal blog

• Brian Klepper at The Health Care Blog

• The always-worth-reading Dr. Centor at DB’s Medical Rants. Dr. Centor, in particular, levels some rather harsh criticisms at the RUC, noting that although he doesn’t consider the committee’s impact an act of “conscious destruction,” he nonetheless believes that the RUC has “done more to negatively impact outpatient continuity, chronic care than any single entity.”

• Maggie Mahar at Health Beat

Some of this criticism must have hit home, because the AMA has posted on its website a .PDF titled “What the RUC IS and Is Not” that specifically addresses some of the charges that have been leveled against it and the RUC.

What Can Be Done?

Maggie Mahar, commenting at Healthcare Renewal, notes that the Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency created to advise Congress on issues affecting the Medicare program, released a report in March 2007 that reaches several of the same conclusions outlined above regarding the RUC and the influence on CMS payment policy wielded by procedure-heavy medical specialties. The report recommends that CMS “establish a group of experts, separate from the RUC, to help the agency” value physician services and set fees. To avoid potential conflicts of interest, the report recommends this group “should include members who do not directly benefit from changes to Medicare’s payment rates, such as experts in medical economics and technology diffusion and physicians who are employed by managed care organizations and academic medical centers.” To help redress the imbalance between primary care payments and specialty payments, several authors of the report contend that “that the relative value units of the physician fee schedule should be at least partly based on a service’s value to Medicare.” In effect, if “analysis of clinical effectiveness for a given condition were to show that one service were superior to an alternative service for a given condition, then Medicare’s process of setting relative values might reflect that.” Were this approach adopted, it might put a premium on preventive care and non-surgical management of chronic illness and reward primary care practitioners for reducing overall costs to the system.

Aside from altering the imbalance and tactics of the RUC and Medicare, what other options do primary care physicians have? The concierge/retainer model certainly has its champions, including the aforementioned Dr. Centor. MDNG has written in the past about the Ideal Micro Practices Project and the micropractice model. Others have pinned their hopes on pay for performance measures. Still others, in a “what’s good for the goose…” mindset, have proposed that healthcare follow the lead of the legal profession and adopt a time-based model of fees and payments.

The American Association of Physicians and Surgeons wants physicians and patients to be allowed to enter into private contracts under the Medicare system, which according to the AAPS would allow patients to “pay doctors more than Medicare allows if they think the service is worth it.”

A 2006 report by the New York chapter of the American College of Physicians called for transitioning to a case-based reimbursement model that would pay physicians, in addition to other fees, a “base fee for coordinating a patient’s care” Such a system would pay primary care physicians “an increasing rate for the amount of time the patient stays in their care. Patients with more chronic illnesses and more frequent visits [would] be categorized as more labor intensive cases, subject to higher reimbursements.”

Finally, Norbert Goldfield, MD, and others at the ACP have introduced the Advanced Medical Home concept. Dr. Goldfield and colleagues claim the fundamental flaw in our current fee-for-service system is that “if you only pay for individual services, you get more services.” This forces primary care physicians who want to “maintain or increase their (inflation adjusted) incomes” to “increase the volume of patient visits and associated services.” The .PDF linked to at the beginning of this paragraph defines the goals, characteristics, and benefits of the “advanced medical home” model, and outlines a series of payment reforms that would make it possible to practice “patient-centered care promoting improved outcomes in terms of quality and resource use.”

The number of proposed solutions and scope of the reforms they call for serves only to underscore the seriousness of the problem confronting primary care medicine. Will any of these solutions prevail and ensure the long-term health and viability of the branch of medicine that is arguably the foundation of our healthcare system? Only time will tell, but it is encouraging to see the debate on this issue grow in intensity and be taken up by more and more stakeholders.

SIDEBARThe Medicare Problem

The American College of Physicians also places much of the blame on Medicare, noting that as the largest payer in the country, its policies and decisions are often closely followed by managed healthcare organizations and private insurers.

The ACP cites several Medicare policies that it claims “adversely affect primary care:”

• Undervaluing the evaluation and management (E/M) clinical services that are predominately provided by primary care physicians.

• Using methodologies to determine the relative value units (RVUs) for each service that overvalue some services/procedures to the detriment of other services in Medicare’s budget neutral system.

• Not paying for those services required to allow the primary care physician to provide patient-focused, longitudinal, coordinated care.

• Using a yearly fee update formula — the sustainable growth rate (SGR) – that projects annual cuts in physician fees of approximately 5 percent through 2011and has a disproportionately adverse impact on primary care physicians.

• Providing incentives for volume of services with no regard to the quality or efficiency of the clinical service provided.